RCAT reflects symptom control and quality of life in allergic rhinoconjunctivitis patients

Efficacy And Safety of Acupoint Catgut Embedding for Perennial Allergic Rhinitis: Protocol for a Randomized Clinical Trial

BACKGROUND

Allergic rhinitis (AR) is a noninfectious chronic inflammatory disease of the nasal mucosa characterized mainly by itching, sneezing, nasal congestion, and rhinorrhea. It is mediated by immunoglobulin E (IgE). AR is one of the most common allergic diseases globally, affecting 10% to 20% of the population worldwide, with some regions even reaching rates as high as 50%, posing a global health issue. The prevalence of AR has been increasing since the 1960s, with a significant increase in recent years. At present, modern medicine-including desensitization therapy, the use of antiallergic drugs, antihistamines, hormones, and other treatments-can improve symptoms or regulate the immune system. However, both short- and long-term efficacy remain limited, as symptoms often recur after treatment cessation, and long-term drug use is associated with toxicity and side effects.

OBJECTIVE

Acupoint catgut embedding (ACE) therapy is widely used to treat AR in China. ACE therapy has been reported to be effective in managing the symptoms of AR, but the evidence faces methodological limitations. Therefore, we designed a parallel-arm, randomized controlled, multicentered, placebo-controlled, and single-blinded trial to evaluate the efficacy and safety of ACE therapy for AR.

METHODS

This study will be a parallel-group, patient-blind, placebo-controlled randomized controlled trial conducted in the Third Affiliated Hospital of Sun Yat-sen University, Ningxia Chinese Medicine Research Center, and the Affiliated Hospital of Shanxi University of Traditional Chinese Medicine. The trial consists of a 4-week treatment period, along with a 3-month follow-up. After providing written informed consent, eligible participants will be randomized at a ratio of 1: 1 into one of 2 groups: the ACE group receiving treatment and the sham ACE group. Both groups will receive conventional loratadine treatment.

RESULTS

The funding began in January 2022. The study was initiated on February 1, 2025, and will end in February 2026. Patient recruitment has already started, and the study results will be released in March 2026.

CONCLUSIONS

We expect that this research will provide important insights into the efficacy of ACE treatment for AR and generate robust data for the foundation of future research in this field.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2500095634; https://www.chictr.org.cn/historyversionpubEN.html?regno=ChiCTR2500095634.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/63933.

Beyond ARIA: Will e-diaries replace retrospective questionnaires in measuring the severity of allergic rhinitis in clinical research and daily practice?

Retrospective questionnaires are used since decades to assess the severity and/or control of allergic diseases. Applications on smartphones have recently facilitated the use of prospective clinical diaries, based on questionnaires filled every day by the patient. Once limited to clinical trials, these e-diaries, based on validated disease control scores and visual analogue scales, permit a quantitative day-by-day measure free of recall bias. Given the advantages of this procedure, its use could be extended to the daily clinical practice. E-diaries may facilitate (1) a more precise identification of the culprit allergen in the diagnostic work-up of poly-sensitized patients, (2) the stratification of patients for treatment, (3) the follow-up of the patients under treatment for optimized shared decision-making, and (4) a careful assessment of preventive therapies. While a few apps are being used in scientific studies, consensus on their use in daily practice should be reached and guidelines for specialists should be elaborated by scientific associations.

Correlation of the combined symptom and medication score with quality of life, symptom severity and symptom control in allergic rhinoconjunctivitis

Background

The European Academy of Allergy and Clinical Immunology recommended the Combined Symptom and Medication Score (CSMS) as primary endpoint in clinical trials on allergen-specific immunotherapy (AIT) in allergic rhinoconjunctivitis. Here, the correlation between the CSMS and the validated standardised Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ(S)), Rhinitis Control Assessment Test (RCAT) and Visual Analogue Scale (VAS) was analysed.

Methods

Two prospective, multicentre, non-interventional studies on tree pollen, grass pollen and house dust mite allergic patients were performed. The first study comprised 167 patients receiving AIT (AIT population), and the second included 56 patients treated with symptomatic medication only (control population). For up to two seasons (pollen)/exposure periods (house dust mites), participants documented their symptoms and medication intake in a CSMS diary, including VAS. In addition, the standardised RQLQ(S) and the RCAT were completed during study visits.

Results

Comparison between CSMS and RQLQ(S) revealed a positive correlation in the AIT population (r = 0.426) and in the control population (r = 0.569). For CSMS and RCAT, a negative correlation with r = -0.409 (AIT) and r = -0.547 (control) was shown. Positive correlation between CSMS and VAS was also demonstrated with r = 0.585 (AIT) and r = 0.563 (control).

Conclusion

These results support the assumption that the CSMS correlates with quality of life, symptom severity and symptom control on the one hand, while the moderate strength of correlations on the other hand mirrors distinctions of the CSMS compared to the assessments used here.

Efficacy and Safety of Modified Yupingfeng Nasal Spray in Controlling the Recurrence of Persistent and Moderate-Severe Allergic Rhinitis: Study Protocol for a Multicenter, Open-Label, Randomized, and Parallel-Arm Trial

Background. Recurrent episode of allergic rhinitis (AR) is one of the leading illnesses that affects patients. However, there is little research evidence to support pharmacotherapy for AR recurrence. Therefore, this study was designed to explore the efficacy of pharmacotherapy in the control of the recurrence of AR. Methods. In this study, a multicenter, open-label, randomized, and parallel-arm trial will be conducted at three study centers. A total of 190 subjects aged 18–65 with persistent and moderate-severe AR (Qi deficiency and blood stasis syndrome) will be randomly assigned to receive the modified Yupingfeng nasal spray or mometasone furoate aqueous nasal spray. When subjects’ rhinitis control assessment test (RCAT) score is >21 for two weeks, they will stop taking the medication and enter the follow-up. Once a relapse occurs, the time point will be recorded, and the follow-up stops. The primary outcome is the six-month recurrence rate of AR after intervention withdrawal. The secondary outcomes are the one-month recurrence rate of AR, the RCAT score, the duration of follow-up, the duration of medication, the nasal endoscopic results, and questionnaires to evaluate symptoms, signs, and quality of life. The mechanism outcomes include some indicators that may be associated with AR recurrence. In addition, electrocardiograms and other safety indicators will be applied to evaluate the drug’s safety. Discussion. This is the first study to explore the efficacy of traditional Chinese medicine nasal spray on AR from the perspective of controlling recurrence. The results of this trial may provide valuable clinical evidence for controlling the recurrence of this disease by pharmacotherapy. Trial Registration. This study was registered with registration number ChiCTR2100047053 (Chinese Clinical Trial Registry, https://www.chictr.org.cn/showproj.aspx?proj=127432 on June 7, 2021).

Combined Exposure to Birch Pollen and Thunderstorms Affects Respiratory Health in Stockholm, Sweden-A Time Series Analysis

Background: Thunderstorm asthma is a term used to describe surges in acute respiratory illnesses following a thunderstorm and is often attributed to an intense exposure to aeroallergens. Several episodes of thunderstorm asthma have been observed worldwide; however, no such cases have been described in Sweden. In Sweden, the most prominent exposure to air-borne pollen occurs during the blooming of the birch. We aimed to explore the associations between respiratory health and the combined exposure to thunderstorms and birch pollen. Methods: We investigated the association between the daily numbers of outpatient visits due to respiratory cases and the combined exposure to thunderstorms and birch pollen during the period of 1 May–31 September in 2001–2017, in Stockholm County, Sweden, by using time series analysis with log linear models. Results: We detected noticeable increases in the number of outpatient visits on both the same day (max 26%; 95% CI 1.16–1.37) and the day after (max 50%; 95% CI 1.32–1.70) the occurrence of a thunderstorm, when the concentrations of birch pollen and the number of lightning discharges were within the highest categories. Conclusions: It is possible that co-exposure to heavy thunderstorms and high concentrations of birch pollen affects the respiratory health of the Stockholm population. To the best of our knowledge, this is the first study addressing the thunderstorm-related respiratory illnesses in Sweden and the effects of birch pollen. Our study may be important for future public health advice related to thunderstorm asthma.

The Effectiveness of the Bacteria Derived Extremolyte Ectoine for the Treatment of Allergic Rhinitis

Nonpharmacological therapies with a good tolerability and safety profile are of interest to many patients with allergic rhinitis, as a relevant proportion of them have reservations about guideline-concordant pharmacological therapies due to their local irritations and side effects. Ectoine is a bacterial-derived extremolyte with an ability to protect proteins and biological membranes against damage caused by extreme conditions of salinity, drought, irradiation, pH, and temperature. Evidence from preclinical and clinical studies attests its effectiveness in the treatment of several inflammatory diseases, including allergic rhinitis. In this review, we analyzed 14 recent clinical trials investigating ectoine nasal spray in patients with allergic rhinitis and/or conjunctivitis, including sensitive patient groups like children or pregnant women. Some studies investigated monotherapy with ectoine; others investigated combination therapy of ectoine and an antihistamine or a corticosteroid. Analysis of the study results demonstrated that patients with mild-to-moderate symptoms of allergic rhinitis can be successfully treated with ectoine-containing nasal spray. When applied as monotherapy, ectoine exerted noninferior effects compared to first-line therapies such as antihistamines and cromoglicic acid. Using ectoine as an add-on therapy to antihistamines or intranasal glucocorticosteroids accelerated symptom relief by days and improved the level of symptom relief. Importantly, concomitant treatment with ectoine was proven beneficial in a group of difficult-to-treat patients suffering from moderate-to-severe rhinitis symptoms. Taken together, the natural substance ectoine represents a viable alternative for allergic rhinitis and conjunctivitis patients who wish to avoid local reactions and side effects associated with pharmacological therapies.

B-cell responses in allergen immunotherapy

PURPOSE OF REVIEW

The establishment of long-term clinical tolerance in AIT requires the involvement of basophils, mast cells, allergen-specific regulatory T and B cells, downregulation of effector type 2 responses, and increase in production of specific IgG, particularly immunglobulin G4 (IgG4) antibodies. This review aims to provide an overview of the role of B cells in AIT, their mechanism of action, and their potential for improving AIT.

RECENT FINDINGS

In-depth research of B cells has paved the way for improved diagnosis and research on allergic diseases. B cells play a central role in allergy and allergen tolerance through the production of immunglobulin E (IgE)-blocking antibodies. However, an increasing body of evidence has emerged supporting a role for B cells in regulating immune responses that extends beyond the production of antibodies. Regulatory B cells play an important role in immunosuppression, mediated by secretion of anti-inflammatory cytokines.

SUMMARY

Successful AIT establishes the reinstatement of immune tolerance toward allergens, reduces allergic symptoms, and improves clinical treatments in patients. B cells play a central role in this process through antibody-independent immune regulatory processes in addition to the production of IgE-blocking antibodies.

Birch pollen allergy in Europe

Birch and other related trees of the families Betulaceae and Fagaceae (alder, hazel, oak, hornbeam, chestnut, and beech) constitute the birch homologous group. This grouping is primarily based on the extensive IgE cross-reactivity of allergen homologs to the major birch allergen Bet v 1. Birch pollen is the most dominant tree pollen in Northern and Central Europe and is a major cause of allergic rhinitis and, possibly, asthma symptoms. Over the last few decades, levels of birch pollen have risen and the period of exposure has increased due to climate changes. Subsequently, the prevalence of birch pollen sensitization has also increased. The cross-reactivity and sequential pollen seasons within the birch homologous group create a prolonged symptomatic allergy period beyond birch pollen alone. Furthermore, many plant food allergens contain homologs to Bet v 1, meaning that the majority of patients with birch pollen allergy suffer from secondary pollen food syndrome (PFS). As a result, the negative impact on health-related quality of life (HRQoL) in patients allergic to birch pollen is significant. The purpose of this manuscript was to narratively review topics of interest such as taxonomy, cross-reactivity, prevalence, clinical relevance, PFS, and HRQoL with regard to birch pollen allergy from a European perspective.

Shortened up-dosing with sublingual immunotherapy drops containing tree allergens is well tolerated and elicits dose-dependent clinical effects during the first pollen season

Background

This study compared a rapid home-based up-dosing schedule for sublingual immunotherapy (SLIT) drops containing tree pollen allergens with two previously established schedules. Furthermore, the clinical effect of the SLIT was investigated with respect to patients’ first pollen season under treatment.

Methods

In this open-label, prospective, patient-preference, non-interventional study, local and systemic reactions were compared between three up-dosing groups using a SLIT formulation containing birch, alder, and hazel pollen extracts (ORALVAC^® Compact Bäume). Clinical improvement after patients’ first season under treatment was analysed using symptom scores, ARIA classification, symptom control, and the use of symptomatic medication and was compared with data from the previous, pre-treatment pollen season. As the real-life study design allowed no placebo group, the late-treated patients (co-seasonal) served as a control, and crowd-sourced symptom data from persons with hay fever were used from a free web-based online diary.

Results

In 33 study centres in Germany and Austria, 164 patients were included. The treatment was well tolerated, without difference between the groups during the up-dosing phase. At the end of the assessment, 96.1% rated the tolerability of the treatment as good or very good. Local reactions were mostly mild in severity and no serious adverse events occurred. Symptom scores decreased from the 2016 pollen season to the 2017 pollen season. As for the ARIA classification, 79.0% of patients had persistent, moderate-to-severe rhinitis before treatment, but only 18.6% had the same classification after treatment. In all, 62.4% of patients achieved symptom control, and 34.3% of patients required no symptomatic medication after treatment. The rhinoconjunctivitis score was 34.4% lower for pre-seasonal treatment initiation than for the control group. Crowd-sourced symptom load indices showed that the 2016 season caused slightly more symptoms; however, it is assumed that this difference of 0.3–0.5 (score range 0–10) was of less clinical relevance.

Conclusion

The treatment administered using the rapid home-based up-dosing schedule was safe and well tolerated. Symptom relief and reduction in medication use were observed during the first pollen season with SLIT.

Trial registration number

NCT03097432 (clinicaltrials.gov).

Validation of Patient-Reported Outcomes for Clinical Trials in Allergic Rhinitis: A Systematic Review

Although regulatory authorities have recently recommended the use of a combined symptom-medication score as a primary efficacy end point, none has been psychometrically validated. Here, we sought to determine to what extent allergic rhinitis (AR)-related patient-reported outcomes (symptom scores, medication scores, disease control scores, and satisfaction or quality-of-life scales) have been assessed for construct, content, and/or criterion validity, reliability, responsiveness, and the minimal clinically important difference. We searched the PubMed database from January 1997 to June 2018 with logical combinations of key words related to validation, AR, and patient-rated outcomes and scales. From a total of 1705 potentially relevant publications, 55 were reviewed. Despite the current emphasis on a combined symptom-medication score for evaluating the efficacy of allergen immunotherapy in AR, symptom scores have not been extensively validated, and we did not find any publications describing the validation of a medication score. Disease control scales (mainly the Rhinitis Control Assessment Test, the Control of Allergic Rhinitis and Asthma Test, and the Allergic Rhinitis Control Test) and health-related quality-of-life scales (mainly the Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and the mini-RQLQ) have been extensively validated in AR but have some practical disadvantages as primary efficacy criteria in clinical trials.